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Pericardium
Published in Mary N. Sheppard, Practical Cardiovascular Pathology, 2022
There is obliteration of the pericardial cavity by granulation tissue during healing of an acute episode of fibrinous or serofibrinous pericarditis or resorption of chronic pericardial effusion. The granulation tissue gradually contracts over time and encases the heart and may become calcified (Figs. 12.13a,b). This rigid, thickened pericardium limits the ventricular filling. Histopathological examination of the constricted pericardium will show fibrotic thickening, fibrin deposition with organization, and nonspecific inflammation. A proliferation of the pericardial mesothelial cells occurs with thickening. Although rare, restrictive myopericarditis is restrictive ventricular physiology resulting from pericardial fibrotic disease extending into the underlying myocardium.4 Pericardiectomy is the only definitive management of chronic constrictive pericarditis. Extensive penetration of the myocardium by fibrosis and calcification is associated with poor outcome. Removal of both the visceral and parietal pericardium is required, which is associated with increased morbidity and mortality. Although curative, every procedure has associated risks, so it should be reserved for patients not responding to medical management.
Radiotherapy in cancer patients
Published in Susan F. Dent, Practical Cardio-Oncology, 2019
Girish Kunapareddy, Adarsh Sidda, Christopher Fleming, Chirag Shah, Patrick Collier
With regard to the pericardium, chronic pericardial remodeling can occur months to years after initial radiotherapy, characterized by recurrent inflammation, fibrosis, and calcification that may eventually result in constrictive pericarditis (Figure 4.4). Pericardiectomy can be considered for very symptomatic patients, but in this setting surgery is associated with very high morbidity and mortality.
Pericardial disease in the elderly
Published in Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich, Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
Pericardiocentesis may alone be therapeutic in patients with effusive-constrictive pericarditis, although it usually does not fully reverse the underlying condition in all the patients. In patients for whom no significant benefit is achieved after pericardiocentesis, pericardiectomy must be performed (4,56). Usually, these patients require a visceral pericardiectomy which is often more difficult as it requires a sharp dissection of many small fragments until an improvement in ventricular motion is observed. Thus, this procedure should be performed only at centers with sufficient expertise for surgical treatment of constrictive pericarditis. In very few patients, constrictive pericarditis may be due to a reversible inflammation of the pericardium (like post-viral pericarditis), the pericardial effusion may often resolve after treatment with anti-inflammatory medications; this condition is known as transient constrictive pericarditis. In these patients, a trial of anti-inflammatory therapy is reasonable before considering an invasive approach (1–4,51).
Image focus: an uncommon cause of isolated right-sided heart failure
Published in Acta Cardiologica, 2020
Bert Zwaenepoel, Ann-Catherine Soenen, Els Viaene
Tuberculous pericarditis is an important complication of tuberculosis. The diagnosis is often delayed or missed, resulting in late complications. The most serious sequel is constrictive tuberculous pericarditis. As seen in Figure 1, cardiac constriction gives rise to a typical pattern on echocardiography. Constriction can be due to different causes (radiation therapy, previous cardiac surgery, repeated pericarditis, etc.). However, tuberculosis should always be kept in mind as the estimated number of new TB cases increases steadily over the past few years. Once the diagnosis is made, prompt anti-tuberculous therapy should be initiated, apart from diuretics to relieve the signs of right-sided heart failure. Pericardiectomy should be considered for selected patients who have failed to response to medical therapy.
Massive purulent pericarditis presenting as cardiac tamponade
Published in Baylor University Medical Center Proceedings, 2020
Azka Latif, Apurva D. Patel, Toufik Mahfood Haddad, Chetan Lokhande, Michael Del Core, Dennis Esterbrooks
The mainstay of therapy is empiric antimicrobial therapy and adequate pericardial drainage to ensure hemodynamic stability. Empiric antimicrobial therapy should include coverage for gram-positive and gram-negative bacteria, anaerobes, and fungal organisms in immunocompromised patients. Pneumococcus is commonly associated with contiguous intrathoracic spread (pneumonia), while Staphylococcus aureus is mostly seen in hematogenous spread.9–11 Although current guidelines are lacking regarding the duration of treatment, most infectious disease experts recommend therapy for 4 to 6 weeks or at least until resolution of symptoms. Therapeutic and diagnostic pericardiocentesis should be performed if suspicion of purulent pericarditis is high. Recently, pericardial drain placement with intrapericardial saline or fibrinolytic instillation to lyse the loculated effusions has been described, thus avoiding an open surgical approach.5 Bacterial pericarditis progresses to constrictive pericarditis in 20% to 30% of cases, and then pericardiectomy is the treatment of choice.12
Multimodality imaging for the diagnosis and treatment of constrictive pericarditis
Published in Expert Review of Cardiovascular Therapy, 2019
Michael Chetrit, Natalie Natalie Szpakowski, Milind Y. Desai
Pericardiectomy has classically been viewed as a high-risk procedure with a significant bleeding risk and associated mortality. In a series dating from 1936 to 2013, pericardiectomies performed before 1990 were associated with a mortality rate of 14%, while those after 1990 were as low as 5.2% [35]. In one series of patients undergoing pericardiectomy for pericarditis, mortality was found to be 0%, suggesting the underlying etiology resulting in constriction rather than the surgery drives the risk [36]. This is particularly true for patients with mixed restrictive constrictive disease, which is associated with a worse outcome. Consequently, pre-procedural imaging is paramount. Echocardiography plays a major role in determining mixed or isolated diseases, while a preoperative CCT is virtually mandatory to assess calcium burden and the location of the calcium. Furthermore, not infrequently are patients undergoing a redo cardiac surgery and the ability to identify substernal critical vascular structures is important [37]. Finally, active inflammation is a major risk for bleeding and overall mortality, particularly in radiation-associated heart disease with constriction. CMR plays a fundamental role in monitoring active inflammation and identifying the optimal time to undergo a pericardiectomy. Traditional biomarkers have typically normalized by the arsenal of anti-inflammatory medications and are less reliable in these situations. Lastly, CMR can also identify myocardial atrophy and fibrosis which, in high amounts, has been associated with poor outcomes [38].